Continuing to Prepare for the Transition to ICD-10-CM/PCS

Transcription

1 HIPAA COW Amy Richardson, RHIA October 19, 2012 Objectives Demonstrate a basic understanding of ICD-10-CM/PCS code sets Explain benefit and value of ICD-10- CM/PCS Identify and articulate challenges for organizations and providers 2 Objectives Explain impacts of ICD-10-CM/PCS on an organization Demonstrate knowledge of ICD-10- CM/PCS effect on data management Address technology and EDI transitions Explain local ICD10 initiatives and resources 3 1

2 We have a date! New Timeline Allows Increased training time Coding mitigation Dual coding Computer-assisted coding System preparation Financial analysis ICD-10-CM US Clinical Modification of the World Health Organizations (WHO) ICD-10 Diagnostic Codes only ICD-10-PCS What is ICD-10? Developed under contract by CMS to replace ICD-9-CM procedure coding system 6 2

3 United States ICD-10 7 Value of ICD-10 Accurate claims processing for reimbursement Data comparison for outcomes measurement Quality improvement Resource utilization Best practices Medical research 8 What is the Impact? Affects multiple areas Cost and budget Contracts Vendor readiness Training & education Communication Data & reporting Reimbursement & cash flow Resources 9 3

4 Who Must be Compliant? 10 Non-Covered Entities Workers Compensation Auto Insurance Disability Insurance plans Quality Measures Reporting National Quality Forum (NQF) National Committee for Quality Assurance (NCQA) HEDIS 11 ICD-10: Consists of two parts Diagnosis Codes Procedure Codes 12 4

5 One-to-Many Relationship Sprain and strain of ankle unspecified site Sprain and strain of ankle, Deltoid ligament/internal collateral ligament Sprain and strain of ankle, Calcaneofibular (ligament) 4 ICD-9 Codes Turns into 72 ICD-10 Codes Sprain and strain of ankle, Tibiofibular (ligament) distal 13 Structure Differences-CM ICD-9-CM 3-5 characters First character is numeric or alpha Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3 characters ICD-10-CM 3-7 characters Character 1 is alpha All letters except U Characters 2-7 are alpha or numeric Always at least 3 characters Use of decimal after 3 characters 14 ICD-10-CM Structure - Format X X X. X X X X 15 5

6 Diagnosis Code Structure ICD-9-CM Sore Throat ICD-10-CM. J Sore Throat (acute) NOS 16 Structure Differences-PCS ICD-9-CM 3-4 characters All characters are numeric Always at least 3 characters Use of decimal after 2 characters Index by operation name Tabular listing with notes ICD-10-PCS 7 characters All characters are alpha or numeric All letters except I and O Every code is 7 digits No decimal points Index by root operation (no eponyms) Tabular listing in table format 17 ICD-10-PCS Structure Characters (Med/Surg) Section Root Approach Operation Body System Body Part Device Qualifier 18 6

7 Procedure Code Structure ICD-9-CM Procedures ICD-10-PCS Closed [endoscopic] biopsy of esophagus 0 D B 5 8 Z X Excision of Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic 19 CMS Website for Downloads ICD-10 CM 2_ICD10CM_and_GEMs.asp#TopOfPage ICD-10 PCS _ICD10PCS.asp#TopOfPage 20 Organizational and Provider Challenges Understanding, and Engagement Reporting and Data Analysis Staffing, Productivity and Training Cash Flow and Denied Claims 21 7

8 Financial Impact 22 Reality Over 1/3 of health plans have completed their assessment, but 1/4 are less than halfway done About 1/2 of vendors are less than halfway complete with product development 23 Getting Started Assessments Inventory Contact Vendors Gap Analysis Education & Training Budget & Project Plan 24 8

9 Assessments Departments Early education Standard questions 25 Departments Quality Research Admissions Lab Radiology Cardiology Utilization Management GI Lab OR CDI Contracts Medical Staff Financial Counselors Clinics 26 Sample Questions Identify process impacted by ICD-10 Map workflow Identify barriers Identify applications and reports Policy, procedures and forms Educational needs and tools Future activities 27 9

10 Assessments HIM/Financial Areas Workflow Staff productivity Denials management process 28 Coding Productivity Productivity Current national productivity standards o 3-5 inpatient records per hour o outpatient clinic records per hour Causes of Decreased Productivity o Locating documentation in the record o Unfamiliarity with coding system 29 Humber River Regional Hospital (HRRH) Canada ICD-9-CM (April 2002) charts/hr Start ICD- 10 (July 2002) charts/hr ICD-10 (April 2003) charts/hr Inpatient Day Surgery Emergency

11 Documentation Impacts Locating documentation in the record Unfamiliarity with coding system 31 PFS Departmental Assessment Current workflow Denials management process Dirty claims Reporting Staffing and productivity Payer inventory and readiness 32 Contracting Department Assessment Inventory Payers Expiration dates ICD-9-CM codes Documentation review High volume vs. high dollar 33 11

12 Information Systems Assessment Applications Reports Interfaces Rules/Alerts Problem Lists 34 Impacted Systems Encoding & Abstracting Case Mix Billing / Financial Registrations / Scheduling ABN Decision Support Clinical Documentation CPOE Registries Claims Submission Software Utilization Management Quality Management Pharmacy System Case Management Medical Necessity Software Disease Management Radiology / PACS Laboratory Data Warehouse 35 Application Inventory Identify each vendor Inventory all applications Inventory databases Current and required versions Identify interfaces 36 12

13 Vendor Contact Version Cost Timeline Testing Plan 37 Application GA Dates 38 Identified Applications Now What? Analysis of required system changes Field size expansion Change to alphanumeric Interface changes Table structures Prioritize Systems Systems must accommodate the transmission of ICD-9-CM and ICD- 10-CM/PCS simultaneously 39 13

14 Additional Impacts Rules and alerts Problem lists Diabetes -check blood sugar -call if > 200mg/dL 40 Testing Test systems Accommodate test patients Running simultaneously with production system Test with vendors Testing scenarios All application functionality All interfaces All databases All reports 41 Data Management 42 14

15 Where s the Data Found? HIM Database Clinical Data Repository Radiology Database Registries Internal Data Departmental Databases Laboratory Database Patient Accounts Database Pharmacy Database Other departmental systems decision support 43 Where are the Reports? Identify report Source systems Primary, secondary Internal or external Databases 44 Reports Inventory External CORE measures Benchmarking Registries Regulatory HIE State Reporting Internal Patient Care Quality & UR Registries Billing & Reimbursement Research Regulatory 45 15

16 What is the Priority? Internal or external Regulatory Research and grants Revenue resource Day to day operations 46 How do we Complete the Report Rewrite? Report parameters Development will require more coding knowledge Complete reanalysis for procedures ono chapters or code ranges ofocus on root operations 47 GEMs Definition GEMs General Equivalence Maps Maps attempt to find corresponding codes between two code sets Many times, the relationship is not that easy to establish Not a simple crosswalk _and_gems.asp 48 16

17 GEMS Tools Multiple sources Multiple variations Multiple interpretations Multiple payment options 49 Documentation and Education 50 Focus on Documentation 51 17

18 Execute Documentation Plan Identify documentation trends What s uncodeable? What s codeable but nonspecific? Which service lines will suffer most from lack of documentation? Who are your repeat offenders? Where is the new documentation found in the record? 52 If You Build it Coders Only Coders Only Coders Only tell the coders where to find it! 53 Documentation Trends 54 18

19 Asthma Severity Mild intermittent Mild persistent Moderate persistent Severe persistent 55 Noncompliance Dietary regimen Dialysis Other medical treatment Medication regimen Which medication? Intentional (e.g. financial hardship) Unintentional (e.g. age-related debility) 56 Orthopedics What they aren t saying Specific part of bone Laterality Pathological vs. traumatic Displaced vs. nondisplaced Specific bone/joint operated on 57 19

20 Surgical Procedures Coronary bypass procedure Harvesting of saphenous vein graft Greater or lesser saphenous vein? Gastrointestinal procedures What specific part of intestine removed? Lysis of omental adhesions Greater or lesser omentum? Lymph node dissection Entire chain or partial excision? 58 Nonsurgical Procedures Mechanical ventilation Total ventilation time Includes weaning Time increments (consecutive) o Less than 24 hours o hours o More than 96 hours Blood transfusions Route Blood product Autologous vs. nonautologous 59 Surprises! Postoperative pulmonary embolism Artery or vein? Benign paroxysmal positional vertigo Right or left ear? Bilateral? Nonspecific codes and laterality Senile cataract Not specific enough to code to right, left or bilateral eyes 60 20

21 Coding Education ICD-10-CM/PCS will require more knowledge of medical terminology anatomy and physiology (A&P) pathophysiology/disease process how procedures are performed What will it take to get coders to the level they need to be? 61 Training Physicians Incorporate ICD-10 language into current queries and templates Utilize ICD-10 documentation results to create customized training Educate on ICD-10 reimbursement impact 62 Before ICD-10-CM/PCS Eliminate coding and claims backlogs Prepare for cash flow variances Create contingency plans Run parallel systems 63 21

22 After ICD-10-CM/PCS Maintain parallel systems until all claims paid Leverage specificity of the coding system Implement new criteria or requirements Track claim rejections and appeals 64 Thank You! Any Questions? Haugen Consulting Group 65 References AAPC. Coder s Roadmap to ICD-10. Retrieved from AHIMA e-him Workgroup on the Transition to ICD-10-CM/PCS. Transitioning ICD-10-CM/PCS Data Management Processes. Journal of AHIMA 80, no.10 (October 2009): Retrieved from k1_ hcsp?ddocname=bok1_ AHIMA/ CCHIIM. ICD-10 Continuing Education Requirements for AHIMA Certified Professionals (& Frequently Asked Questions for Recertification). (October 5, 2010). Retrieved from Qs.pdf Averill, Richard; Bowman, Susan. There Are Critical Reasons for Not Further Delaying the Implementation of the New ICD-10 Coding System. (July 2012) Journal of AHIMA

23 References CDC/National Center for Health Statistics. ICD-10-CM & ICD-10- PCS Codes Sets. (March 1, 2011). Retrieved from Herman, Robert. HHS Finalizes One-Year Delay of ICD10 to /24/12. Retrieved from Sullivan, Tori E; McNeill, Gale C.; Wall, Kathleen E. Implementing ICD-10-CM/PCS for Hospitals, A Project Guide and Toolkit, AHIMA (2010). Williams, Willie III PMP. ICD-10 White Paper: Data Impact Across the Enterprise. (April 2011). Retrieved from 10andtheSystemsThatAreImpactedFINAL042211TKCG.pdf Wollman, John. ICD-10: A Master Data Problem. Retrieved from 10_A_Master_Data_Problem pdf 67 23